A 70-year-old female with no relevant history was diagnosed with a synchronous colorectal cancer.
The tumors were located at the splenic flexure and 14 cm from the anal verge. The immunohistochemistry of the repair genes was normal
Clinical staging by CT scan was negative and she underwent radical surgery using the Cecil approach.
After placement of the transanal access platform, the tumor was located. We introduced gauze to occlude the lumen and avoid distention of the colon.
A prolene running suture was made so that the knot involved all elements down to the muscle layer. The leading surgeon and the assistant must be coordinated and the movements should be delicate, as the working field is small.
Special caution must be taken with the depth at the anterior wall were the mesorectum is thinner and it is easier to involve surrounding structures in the knot such as the vagina. The knots must be made at the same height to achieve a symmetrical pursetring.
Now the rectal lumen is closed and the next step is to perform a circumferential tattoo 1cm away from the knot. The down to up dissection goes from the mucosa to the submucosa, the muscle layer and the mesorectum, reaching the holy plane.
The surgeon must imagine that they are dissecting a cylinder, and should go from an evident correct plane towards the undissected rectal wall. A second pursestring was created to close the rectal stump during the anastomosis.
It seems that in this case the anterior knot involved the vagina as it moved together with the rectal stump. Careful dissection was performed, but the knot was sectioned using the hook and the rectal lumen was opened.
At this stage the rectal lumen had to be closed in order to progress with the procedure. The rectal borders were identified and grasped; at the same time the transabdominal team was clamping the sigmoid colon to control the intraluminal leak of CO2. A prolene running suture was made to solve the problem.
With the 3D visualization system the camera can be far from the working field and still show the anatomical structures, allowing the leading surgeon to work. These are the final knots, which were hand tied.
Now the sealed cavity was restored and the surgery could continue.